COMMUNITY BRIDGES, INC (GLOBE STABILIZATION AND RECOVERY UNIT) - NPI NUMBER 1093960304

Summary

Provider Name: COMMUNITY BRIDGES, INC (GLOBE STABILIZATION AND RECOVERY UNIT)

NPI Number: 1093960304

Clasification: Community/Behavioral Health (251S00000X)

Address:
5734 EAST HOPE DRIVE
SUITE 2
GLOBE, AZ
ZIP 85501

Phone Number: (928) 425-2415



Detailed Information

COMMUNITY BRIDGES, INC is a community/behavioral health in Globe, AZ. The provider is a private or public agency usually under local government jurisdiction, responsible for assuring the delivery of community based mental health, mental retardation, substance abuse and/or behavioral health services to individuals with those disabilities. Services may range from companion care, respite, transportation, community integration, crisis intervention and stabilization, supported employment, day support, prevocational services, residential support, therapeutic and supportive consultation, environmental modifications, intensive in-home therapy and day treatment, in addition to traditional mental health and behavioral treatment. The assigned NPI number for this provider is 1093960304 and is registered as an organization entity type.
The provider Is Doing Business As Globe Stabilization And Recovery Unit.

The provider's business address is:

5734 EAST HOPE DRIVE
SUITE 2
GLOBE, AZ
ZIP 85501
Phone: (928) 425-2415
Fax: (928) 425-2464

The provider's authorized official is John F Hogeboom .
The authorized official title is Vp/coo and has the following contact phone number (480) 831-7566.

The enumeration date for this NPI number is 12/1/2008 and was last updated on 2/19/2015.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 251S00000X Community/Behavioral Health OTC6025 AZ No
2 251J00000X Nursing Care OTC6025 AZ No
3 261QM0850X Clinic/Center Adult Mental Health OTC6025 AZ No
4 261QH0100X Clinic/Center Health Service OTC6025 AZ No
5 261QR0405X Clinic/Center Rehabilitation, Substance Use Disorder OTC6025 AZ No
6 261QR1300X Clinic/Center Rural Health OTC6025 AZ No
7 291U00000X Clinical Medical Laboratory OTC6025 AZ No
8 343900000X Non-emergency Medical Transport (VAN) OTC6025 AZ No
9 251B00000X Case Management OTC6025 AZ Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 Z145164 OTHER AZ MEDICARE PTAN
2 388723 MEDICAID AZ

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1093960304 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name COMMUNITY BRIDGES, INC The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider Other Organization Name GLOBE STABILIZATION AND RECOVERY UNIT Other name by which the organization provider is or has been known.
6 Provider Other Organization Name Type Code 3 Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
7 Provider First Line Business Practice Location Address 5734 EAST HOPE DRIVE The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Second Line Business Practice Location Address SUITE 2 The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
9 Provider Business Practice Location Address City Name GLOBE The city name in the location address of the provider being identified.
10 Provider Business Practice Location Address State Name AZ The State code in the location of the provider being identified.
11 Provider Business Practice Location Address Postal Code 85501 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
12 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
13 Provider Business Practice Location Address Telephone Number 9284252415 The telephone number associated with the location address of the provider being identified.
14 Provider Business Practice Location Address Fax Number 9284252464 The fax number associated with the location address of the provider being identified.
15 Provider Enumeration Date 12/1/2008 The date the provider was assigned a unique identifier (assigned an NPI).
16 Last Update Date 2/19/2015 The date that a record was last updated or changed.
17 Authorized Official Last Name HOGEBOOM The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
18 Authorized Official First Name JOHN The first name of the authorized official.
19 Authorized Official Middle Name F The middle name of the authorized official.
20 Authorized Official Title or Position VP/COO The title or position of the authorized official.
21 Authorized Official Telephone Number 4808317566 The 10-position telephone number of the authorized official.
22 Healthcare Provider Taxonomy Code 1 251S00000X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
23 Provider License Number 1 OTC6025 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
24 Provider License Number State Code 1 AZ The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
25 Healthcare Provider Primary Taxonomy Switch 1 N
26 Healthcare Provider Taxonomy Code 2 251J00000X
27 Provider License Number 2 OTC6025 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
28 Provider License Number State Code 2 AZ The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
29 Healthcare Provider Primary Taxonomy Switch 2 N
30 Healthcare Provider Taxonomy Code 3 261QM0850X
31 Provider License Number 3 OTC6025 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
32 Provider License Number State Code 3 AZ The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
33 Healthcare Provider Primary Taxonomy Switch 3 N
34 Healthcare Provider Taxonomy Code 4 261QH0100X
35 Provider License Number 4 OTC6025 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
36 Provider License Number State Code 4 AZ The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
37 Healthcare Provider Primary Taxonomy Switch 4 N
38 Healthcare Provider Taxonomy Code 5 261QR0405X
39 Provider License Number 5 OTC6025 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
40 Provider License Number State Code 5 AZ The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
41 Healthcare Provider Primary Taxonomy Switch 5 N
42 Healthcare Provider Taxonomy Code 6 261QR1300X
43 Provider License Number 6 OTC6025
44 Provider License Number State Code 6 AZ
45 Healthcare Provider Primary Taxonomy Switch 6 N
46 Healthcare Provider Taxonomy Code 7 291U00000X
47 Provider License Number 7 OTC6025
48 Provider License Number State Code 7 AZ
49 Healthcare Provider Primary Taxonomy Switch 7 N
50 Healthcare Provider Taxonomy Code 8 343900000X
51 Provider License Number 8 OTC6025
52 Provider License Number State Code 8 AZ
53 Healthcare Provider Primary Taxonomy Switch 8 N
54 Healthcare Provider Taxonomy Code 9 251B00000X
55 Provider License Number 9 OTC6025
56 Provider License Number State Code 9 AZ
57 Healthcare Provider Primary Taxonomy Switch 9 Y
58 Other Provider Identifier 1 Z145164 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
59 Other Provider Identifier Type Code 1 01 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
60 Other Provider Identifier State 1 AZ
61 Other Provider Identifier Issuer 1 MEDICARE PTAN
62 Other Provider Identifier 2 388723 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
63 Other Provider Identifier Type Code 2 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
64 Other Provider Identifier State 2 AZ
65 Is Organization Subpart Y
66 Parent Organization LBN COMMUNITY BRIDGES, INC
67 Parent Organization TIN
68 Authorized Official Name Prefix Text MR.
69 Authorized Official Credential Text LISAC

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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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